Whose morality, Whose burden: Abortion, International Development and Grandstanding By Dr RCH Thetard Thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy (Applied Ethics) in the Faculty of Arts and Social Sciences at Stellenbosch University Supervisor Prof. A.A. Van Niekerk March 2020 Stellenbosch University https://scholar.sun.ac.za Declaration By submitting this thesis electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the sole author thereof (save to the extent explicitly otherwise stated), that reproduction and publication thereof by Stellenbosch University will not infringe any third party rights and that I have not previously in its entirety or in part submitted it for obtaining any qualification. Copyright © 2020 Stellenbosch University All rights reserved 2 Stellenbosch University https://scholar.sun.ac.za Abstract The Roe v. Wade decision (1973) by the American Supreme Court is a pivotal moment in American history when the onus of choice about abortion shifted to pregnant women. While this signified victory for one segment of the American population (the pro-choice group), it awoke strong resistance from others (the pro-life group) resulting in long-standing acrimonious conflict. Pro-choice groups affiliated themselves with like-minded groups, including the Democratic Party, who stood for the rights of women to exercise reproductive choices including abortion. Pro-life groups aligned themselves with conservative religious groupings from which emerged the Christian Right. The Christian Right coined the term ‘right-to-life’ which, as part of their anti-abortion ideology, became a rallying cry in pursuit of the establishment of fetal personhood from the moment of conception, a core anti-abortion strategy. They created strong networks with conservative Republicans and subsequently, as a movement, became influential in the national political process and the election of Republican Presidents including Reagan, the two Bush’s and Trump. The Christian Right, in addition, pursued a global effort to strengthen their anti-abortion cause. The combination of domestic and international agendas stimulated the development of a strong American anti-abortion push exemplified by the enactment of the Mexico City Policy (MCP) in 1984. Subsequently, this policy has been typically re-enacted by Republican administrations and rescinded by Democratic administrations. The MCP restricts American Government funding to international NGOs who commit not to provide or promote abortion as a method of family planning, even if funded through alternative sources. Funding to non-compliant institutions is cut. MCP enactment has a severe impact since the American Government is a major funder of development aid, including family planning, globally. Much of this aid in support of family planning service delivery is processed through international NGOs who are active in low resource settings. MCP restrictions on non-compliant NGOs leads to family planning service gaps associated with an increase in maternal morbidity and mortality following a greater burden of unintended pregnancies and unsafe abortions. In addition, service providers are restricted in the provision of information and services related to reproductive choices that they can provide to pregnant women while pregnant women are denied the option of autonomously exercising their choice about pregnancy options including abortion. The imposition that follows MCP enactment together with the associated injustice and harms calls for the evaluation of the policy to determine whether it is just toward those at the receiving end of the policy. The ethical evaluation assesses the internal consistency of the policy and turns to global health ethics to assess the global impact of the policy. The evaluation concludes that the MCP is internally incoherent which weakens the moral foundation for its global application while global health ethics confirms that the policy is unjust and deepens global inequality and inequity. Recommendations are formulated to address the impact of the MCP when enacted. Recommendations aim to mitigate injustice by encouraging compromise between opposing groups as a key mechanism for reducing the impact of the MCP. 3 Stellenbosch University https://scholar.sun.ac.za Opsomming Die beslissing van die Amerikaanse Hooggeregshof oor die opspraakwekkende Roe v. Wade saak (1973) het besluitneming oor aborsie in die hande van swanger vrouens geplaas. Die oorwinning vir een groep van die bevolking (die pro-aborsie groep) laat ‘n ander groep hoogs geaffronteer (die anti-aborsie groep). Die besluit lei tot ‘n lang staande konflik. Die pro-aborsie groep, in assosiasie met enersdenkende groeperings insluitend die Demokratiese Party, het vroue se reg om voortplantings keuses (insluitend aborsie) sonder inmenging van andere aangemoedig. Die teen-aborsie groep, in alliansie met konserwatiewe Christelike groepe, het as ‘n teenvoeter ontstaan wat later ontwikkel het as die ‘Christian Right’. Die ‘Christian Right’ het die idee van die ‘right-to-life’ bevorder met as kerngedagte dat die persoon by bevrugting tot stand kom; hierdie idee word uiteindelik deel van ‘n belangrike anti-aborsie strategie. Die ‘Christian Right’ het hulle invloed uitgebrei na die Republikeinse Party en het gehelp om verskeie Amerikaanse Presidente te verkies, insluitend Reagan, die twee Bush presidente en Trump. Die ‘Christian Right’ beywer hulle sedertdien om die anti-aborsie boodskap wêreldwyd uit te brei. Die binnelandse en buitelandse agendas van die ‘Christian Right’ het bygedra tot die formulering van die ‘Mexico City Policy’ (MCP) in 1984. Sedertdien is die MCP tydens periodes van Demokratiese beheer teruggetrek terwyl dit afgedwing was tydens periodes van Republikeinse beheer. Die doel van die MCP was om Amerikaanse befondsing aan nie-regerings organisasies wat gesinsbeplanning dienste lewer te beperk, tensy die organisasies hulle verbind het om geen aborsie-verwante aktiwiteite te onderneem nie. Die verbod het ook die gebruik van befondsing vanaf nie-Amerikaanse regerings bronne om aborsie aktiwiteite te doen, verbied. Omdat die Amerikaanse regering in belangrike bydra tot internasionale gesinsbeplanning in derde wêreldse lande maak, lei die afdwinging van die MCP tot omvattende en uitgebreide gevolge. Dienslewering deur internasionale nie-regerings instellings in ontwikkelde lande word tipies ingekort met ‘n gevolglike toename in onbeplande swangerskappe asook ‘n toename in onveilige aborsies met ‘n gepaardgaande styging in moederlike morbiditeit en mortaliteit. Die MCP lê ook beperkinge op die inligting wat gesondheidswerkers oor aborsie aan pasiënte kan oordra en die besluite wat swanger vrouens oor hulle eie swangerskap kan neem. Die beperkings wat die MCP bring, lei tot onreg en skade aan mense wat daaraan blootgestel is. In ag genome die globale impak van die MCP, ondersoek hierdie tesis die etiese basis van die beleid om te bepaal of die onreg wat geassosieer word met die MCP, regverdigbaar is. Die evaluering bepaal, eerstens of die samestelling van die beleid intern konsekwent is en tweedens, tot watter mate die beleid se globale gevolge regverdig kan word. Die gevolgtrekking word gemaak dat die interne struktuur van die MCP etiese teenstrydighede toon wat die morele fondasie daarvan belemmer. Die evaluering van die MCP as ‘n beleid binne ‘n raamwerk van ‘global health ethics’ lei tot die gevolgtrekking dat die beleid wêreldwye onreg veroorsaak vir die persone wat daaraan blootgestel is. Aanbevelings word gemaak wat poog om die onreg wat volg uit die beleidsimplementering te bemiddel waarvan kompromie tussen strydende partye belangrik is. 4 Stellenbosch University https://scholar.sun.ac.za Acknowledgements In December 2016 I moved back to Malawi after an absence of 5 years to start up a large integrated health project across approximately half of Malawi. This was shortly after Trump’s election as President and one of the topics of conversation was whether the Global Gag Rule (Mexico City Policy) would be enacted again. A colleague made a comment about certain organizations who were likely to refuse American funding to support service delivery activities based on the principled opposition to the Global Gag Rule. I found this observation intriguing – why should an institution make a principled stand by refusing funding to support service delivery in settings with multiple health needs? What is the basis for justifying such a decision? This subsequently provided the idea for my thesis topic. My subsequent research led to much amazement – much of which is shared in this thesis. At a certain point I became stuck as I tried to determine how I would assess this topic ethically since there were no clear pathways to do this. The thesis expresses some of my ideas in this regard. One of the areas I began to explore was global health ethics and its associated concepts. The more I came to understand, the more my eyes began to open about the context within which I still work in Malawi. What were general expressions of unease or discomfort could now be put into words together with the chain of thinking that enables one to reach conclusions. This was a helpful insight in the world I inhabit here which includes many of the institutions I refer to in this thesis such as government, NGO and donors. I have also seen some of the issues I describe such as conditionality, the need for duty of care, injustice, poverty, etc. I